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Healthy Start, Healthy Future

The Origins Project at Joondalup Health Campus seeks to find answers to some of the most worrying health problems facing children today.

When the triennial Australian Early Development Index was published in 2012 it set off alarm bells for Prof Desiree Silva, the head of paediatrics at the Joondalup Health Campus. The AEDI showed that some areas in the Wanneroo region had the most vulnerable children in Australia where almost 40% were vulnerable in one domain.

While it sounded the alarm, Desiree said it also confirmed her own clinical experience.

“I was seeing (and continues to see) increasing numbers of children with mental health issues – anxiety disorders, autism and ADHD. I have had children as young as seven articulating suicide. These symptoms are becoming more prevalent, their degree is worsening and the age of the children is getting younger,” she said. These children with problems become adults with bigger problems if they are not managed appropriately.”

“In terms of physical health, there are so many more children presenting with allergies and asthma. About 24% of children by age one has eczema and one in 10 has a food allergy.

The children in the Wanneroo survey were not just part of a national average, they were living on the hospital’s doorstep and clinicians had few definitive answers to alleviate their suffering.

“We need to understand why these issues have increased and how we can prevent them or, at least, intervene earlier,” Desiree said.

Buck stops here

The hospital CEO Kempton Cowan when he saw these figures was compelled to do something about it. The hospital draws about 80% of its staff from the local area. It was personal. It was the early stirrings of The ORIGINS Project, a longitudinal pregnancy and birth cohort study that would investigate the foetal origins of many common non-communicable diseases.

Alongside her clinical work, Desiree is also involved with the Telethon Kids Institute and the idea of such a population study with the backing of a CEO whose hospital delivers more than 4000 babies a year was of immediate interest to Paediatric immunologist Prof Susan Prescott whose work on childhood allergies has led her to an intense study of the microbiome.

Susan has published several books – Origins and The Allergy Epidemic for UWA Publishing and co-authored another book with Dr Alan Logan, The Secret Life of Your Microbiome, which will be published in September.

Desiree and Susan are co-directors of The ORIGINS Project, which has had its initial injection of funds from the Health Department, Telethon Kids and Ramsay Health Care.

The ORIGINS Project, which started recruiting in December 2016, will focus on environmental exposures on women during pregnancy and would follow the developmental milestones of the child till the age of five. It marks new territory and, with improving technology, it is hoped the research will penetrate the mysteries of a range of non-communicable diseases that affect so many of the world’s children.

A gut feeling

“Technology has revolutionised the way we understand the microbiome. We think there are a lot of answers to these questions there because 95% of genetic make-up is bacterial, so the idea that we can change our genes is very real. It is likely that a lot of these NCDs are a result of gene changes from some environmental or epigenetic factor,” Desiree said.

So far 300 women have enrolled and researchers are aiming for 10,000 over the next five years and the study will run for 10 years.

“We’re encouraging people to join ORIGINS as early as possible – 10 weeks gestation is ideal – so they can join the sub-studies (see Pxx). The project hopes to answer global questions but individual study participants will also receive real-time feedback.”

“We have factored this feedback into the study because I don’t want information sitting on my desk that can make a difference to someone if problems are detected at the various developmental testings.”

“There is a lot to be said for putting a child on the right trajectory and if we can discover how to pre-program that trajectory so the child will have less chance of being sick or developmentally vulnerable, then that would be a great thing not only for the child but the community as a whole.”

Desiree’s own research interest is in neural disorders. She is involved with Dr James Fitzpatrick’s FASD project in the Kimberley and she has completed her PhD on ADHD in relation to early environmental risk factors. She has just published ADHD Go-To Guide (UWA Publishing) with co-author Dr Michele Toner. The disorder constitutes a significant proportion of her cases.

Parents need help

“I’ve spent a lot of time with children and families with ADHD and realised there wasn’t enough parent-friendly information available explaining the current issues around ADHD and how to manage their child, with and without medication.”

She will be watching with interest what ORIGINS throws up in regards to parents’ use of technology. While there is growing research around children’s use of technology on their behaviour and language development, electronic devices are also coming between parents and their babies.

“I see babies at the six-week check who are not smiling as they should be and then I notice their parents excessively looking at their phone. Early facial expressions create the platform for the brain and parents are simply not spending enough time looking at their young children. When the baby is awake, they need to be engaging with their parents rather than being babysat by an electronic device or have mum or dad glued to their phone.”

“We need hard evidence about the developmental delays caused by the use of electronic devices and then find a way to give parents correct advice.”

Desiree, who was born in Sri Lanka and gained her medical degree in the UK, did her paediatrics training at Princess Margaret Hospital and Darwin 20 years ago. It is there she met Dr Wendy Hoy, a renowned clinician/researcher who has done ground-breaking research into kidney disease in vulnerable populations.

“Wendy has done some unbelievable work on renal disease in Aboriginal communities, especially the Tiwi Islands. She was one of the first researchers to link low-birthweight with kidney disease and diabetes. She asked me to present some of these findings at an international conference in 1994 and that sparked me off and I have been interested in the origins of disease ever since.”

At the TKI, Desiree undertook the ‘swimming pool study’ a research project that looked at how access to a swimming pool in remote communities could positively impact on children’s wellbeing. Her specific interest in mental health continued with her work in ADHD.

“It went neatly with Susan Prescott’s research so we joined our enthusiasms and with a little funding we got The ORIGINS team and project off the ground.”

Burden of mental disorders

“We are currently dealing with enormous mental health issues on the ward and we don’t quite know what to do. The link services at CAMHS are completely overwhelmed with the number of children being referred to them and the severity of impairment so we need to find new ways to reverse that.”

Desiree has been working at Joondalup Health Campus since 1998 and head of department for 10 years and in that time has seen the hospital expand exponentially. The health campus is serving the fastest growing population of any local government in WA. According to the 2012 AEDI data, the City of Wanneroo has a significantly higher percentage of children aged birth to eight (15%) than anywhere in WA.

It has also become a clinical teaching hub with medical students from UWA and allied health students from ECU and Curtin providing exciting opportunities for “youngsters thirsty for research”.

The new 37-bed Telethon Children’s Ward, complete with overnight facilities for parents, was opened in June last year and apart from winning awards for its interior architects, Silver Thomas Hanley, it has lifted the spirit of patients, their families and the health practitioners who treat them.

“The new ward has made a big difference to the atmosphere. People love working there and parents get a good night sleep. Everyone seems a lot happier,” Desiree said.

It offers hope that when the new Children’s Hospital is commissioned it will have a similar effect on morale for staff at PMH, but, of course, the culture of an organisation is much more than bricks and mortar.

Culture and productivity

So what is the secret of this gross national happiness at Joondalup?

“I think the main thing is that people feel valued and you work on people’s strengths. We don’t micromanage but there is mutual respect … that said we have to choose the right people as well. We have a great team of consultants who have exceptional clinical skills and love teaching. It’s one of the few places where you can do neonates and general paediatric training, so we all experience some adrenaline at work. We are really quite busy.”

Desiree also praised the hospital management, which she said supported its clinicians.

“That makes a big difference. It’s not difficult to see the CEO if something is not right and he will attempt to fix it. You don’t feel you have to go through layers to get there. There’s no reason why that model can’t be replicated,” she said.

“Junior staff are happy here and that doesn’t happen by accident. A lot of effort goes into developing a positive culture. There is a sense of growing together and taking people with you. And that is why ORIGINS is a perfect fit here – it is embedded in the daily working life of the hospital and people feel included.”

Desiree also advocates to her staff the importance of switching off and in her own case there’s not too much lazing around a pool.

Feeling her feathers

“I love being fit and adventure travel – hiking, cycling and swimming. I do the Rottnest swim every year with friends. I was a hopeless runner until I got a dog and started running along the beach. That developed into triathlons and fun runs until I ran the New York marathon with a group of friends. I proved to myself I could do that distance so in December just gone I did the full Ironman in Busselton.”

“I’m not competitive – times don’t mean much to me. People kept telling me before the Ironman about what to do when I hit the wall. I was passing people lying on the side of the road hypothermic, vomiting and cramping wondering when I would feel that bad. I didn’t and I finished under the time limit. People have asked me when will I do the next one and I say when I am 60 !”

“That’s my downtime.”

So thrilled with the achievement she gave her three children aged 27, 25 and 23 entry into the half ironman in May as a Christmas present.

“They embraced the most of the training and all finished well, it was incredible. It goes to show you so much is in the mind. If you want to do something, you can do it.”

Origins Offshoots

There is a nest of sub-studies running off the Origins Project:

SYMBA: This study will examine origins of allergic diseases including eczema, asthma, hay fever and food allergies through research into the mother’s gut health and the effects of ‘Prebiotics’. This is a general term for non-digestible dietary fibre which is the substrate for the growth and/or activity of beneficial gut bacteria. This project will recruit pregnant women (during their routine antenatal visits to Joondalup Health Campus) to receive either a prebiotic supplement or a placebo. They will be asked to take the supplement from 18-20 weeks gestation until their baby is six months of age. The study will then examine whether supplementing the mother’s diet during pregnancy and breastfeeding with prebiotic fibre will reduce the development of allergies in her child.

TALK: The aim of this study is to track a large participant cohort from prenatal life to three years of age to understand biological factors that may underpin language development. The data collected will be used to explore several hypotheses relating to the interplay between prenatal testosterone exposure and brain growth, and their relation to language development. The study will recruit 500 pregnant women at their initial antenatal appointment at Joondalup Health Campus (private patients only). The assessment protocol involves two antenatal ultrasounds, a neonatal hearing test, and behavioural assessments at six, 24, and 36 months of age. The protocol will also analyse data collected as part of the ORIGINS study, including umbilical cord blood (for androgen concentrations), and maternal and child DNA samples.

PLAN: The aim of the PLAN project is to test whether a lifestyle intervention in early pregnancy reduces offspring adiposity. Recruitment will take place at 6-8 weeks gestation and follow a 12-week lifestyle intervention program in conjunction with routine antenatal care for private and public patients. The project will use smartphone web-based applications to deliver diet, physical activity and well being advice to women who begin their pregnancy overweight (pre-pregnancy BMI > 25). PLAN will examine epigenetic biomarkers (differential DNA methylation), to determine if these are modified by optimisation of gestational weight gain or associated maternal lifestyle changes. Even small changes in infant adiposity have the potential to change future obesity trajectory.

CARE dads: Expectant fathers get an opportunity to participate in research as well. This study will look at their cardiovascular health. They will provide a blood sample from which red and white blood cells, DNA and RNA will be prepared and stored for future research. They will also be invited to have a cardiovascular health evaluation and be provided feedback. The study will also look at the distribution of Anti-Mullerian Hormone (AMH) in the expectant fathers, and to examine associations of AMH with reproductive hormones (testosterone, luteinising hormone, follicle-stimulating hormone, sex hormone-binding globulin) and with physical and biochemical markers of cardio-metabolic risk (age, exercise, smoking, alcohol, body mass index, waist circumference, blood pressure, lipids, glucose, HbA1c, and presence of metabolic syndrome).